Childbearing, Infertility, and Career Trajectories Among Women in Medicine

This survey study investigates delays in childbearing and rates of infertility among women physicians.


Introduction
While women are increasingly represented within medicine, 1 pervasive gender disparities exist. A landmark 2000 study 2 found that female US medical school graduates were less likely to be promoted to upper faculty ranks, with a 2020 follow-up study 3 finding no narrowing of this gap over time. Women are less likely than men to publish in leading medical journals or hold positions on editorial review boards 4,5 and are less likely to hold academic leadership positions. 6 According to 2021 data from the Association of American Medical Colleges (AAMC), 6 women account for 43% of medical school faculty but 22% of department chairs and 22% of medical school deans.
Although reasons for attrition are unclear and likely complex, fertility and family building may be contributing given the duration and intensity of medical training, which coincides with women's peak reproductive years. Prior research found that women physicians were more likely to delay childbearing and experience infertility compared with nonphysicians. [7][8][9][10][11] While the decision to delay may be underinformed without full understanding how age is associated with fertility, 12,13 physicians may postpone childbearing in spite of this knowledge due to insurmountable career-related pressures. The extent to which fertility knowledge may mediate delayed childbearing and infertility is unknown.
While research has focused on the association of a medical career with fertility outcomes, less is known about the association of family building and parenthood with career. A small survey 14 of physician parents found that women were more likely to have turned down projects or committee participation due to parenting concerns, and a longitudinal cohort study 15 of medical interns found that women were more likely than men to work part time after completion of training, with family consistently cited as the most influential factor in this decision. There is a need to more thoroughly evaluate family building and parenthood as a factor associated with gender disparities within medicine.
The objectives of this study were to characterize patterns of delayed family building and infertility among women physicians, assess differences in fertility knowledge and their association with delayed family building and infertility, investigate factors associated with family building regret, and (4) investigate the extent to which women in medicine may alter their career to balance parenthood and career.

Methods
This cross-sectional survey study was approved by the Northwestern University institutional review board. Participants provided informed consent. The study was conducted in accordance with the American Association for Public Opinion Research (AAPOR) reporting guideline.

Survey Development
Survey development was detailed in a prior publication, 16 as summarized in Figure 1. Briefly, standardized 1:1 interviews exploring perceptions and experiences of fertility, parenthood, and career were conducted among women physicians. Qualitative data were coded in Dedoose version 9.0.107 and used to develop tailored survey items. Questions assessing fertility knowledge were developed with content expertise from reproductive endocrinologists (K.N.G. and E.C.F.) and validated by collaborators with expertise in qualitative and survey research (E.O.C. and P.I.M.). Psychometric evaluation was conducted in a pilot survey among women physicians, with feedback used to inform further revisions and modifications. question, and available categories were Asian, Black or African American, Hispanic or Latino, Middle Eastern or North African, Native Hawaiian or Pacific Islander, White, multiracial (available as an option respondents could choose), and other, with the option to provide a write-in response.
Fertility knowledge was assessed through 3 multiple choice items. First, participants were asked over which age range a cisgender woman's ability to conceive declines most precipitously (25-29, 30-34, or Ն35 years). Then, they were asked to select the likelihood of pregnancy per month with intercourse and cumulative live birth (CLB) per in vitro fertilization (IVF) cycle if a cisgender woman is aged 30 to 34, 35 to 39, 40 to 42, or 43 to 45 years. 17,18 Beliefs about stress and infertility were queried, and the extent to which participants relied on various sources for fertility information was assessed ("not at all" to "extremely").
Delayed family building, infertility, and use of IVF were assessed. Experiences with oocyte cryopreservation (OC) or embryo cryopreservation were queried through multiple choice questions.
Women were asked about factors they believed influenced the decision to pursue cryopreservation, ranging from "not at all" to "extremely." Family building and career regret were explored by asking respondents the extent to which they agreed that they would have changed aspects of family planning or career if they could do it over again ("strongly disagree" to "strongly agree"). Finally, participants were asked whether they had taken specific career measures to accommodate childbearing or parenthood.

Survey Distribution
The survey was distributed through social media March to August 2022. The survey QR code and hyperlink (eFigure 1 in Supplement 1) were distributed through social media, including targeted

Study Participants
Women attending physicians and trainees were invited to participate. Participation was voluntary and uncompensated, and participants provided informed consent. Cisgender men (3 individuals) were excluded. Due to potentially unique circumstances surrounding fertility for transgender men and women, these respondents were also excluded (1 individual). Gay and lesbian women were included. Participants completing 50% of survey items or more were included in the final analysis.

Statistical Analysis
Descriptive statistics were performed, and χ 2 analysis with pairwise, Bonferroni-adjusted z tests were used to test group differences regarding fertility knowledge (assessed by the correct identification of age at fertility decline), delayed family building (having ever vs never delayed), duration of delay (<3, 3-5, or >5 years), and infertility, as well as differences regarding infertility and specific measures of family building regret. P values were 2-sided, and P < .05 was regarded as significant. To evaluate whether these outcomes varied by specialty, associations were tested among obstetrics and gynecology physicians vs those in other specialties and in surgical vs nonsurgical specialties. Data were analyzed using SPSS statistical software version 23.0 (IBM).

Fertility Knowledge
Among all respondents, 824 individuals (78.0%) correctly identified the age of fertility decline of 35 years or older. Most respondents correctly or nearly correctly identified approximate monthly chance of conception by age, with incorrect answers tending to underestimate vs overestimate fertility in most age groups (Figure 2). The most frequently selected likelihood of conception for each group decreased with increasing maternal age, with 930 respondents (88.1%) correctly estimating the chance of conception to be less than 5% among women aged 43 to 45 years ( Figure 2

Delayed Family Building
Most respondents (988 individuals [93.6%]) reported concern regarding the length of training and family planning, with 798 respondents (75.6%) reporting delaying family building due to medical training or specialty choice and 213 respondents (20.2%) reporting not delaying ( Table 2). Results did not vary by specialty. Of respondents who delayed, 182 individuals (22.8%) had delayed more than 5 years. Reasons for delay included lack of schedule flexibility or time, stress, financial strain, and concern about burdening colleagues. Among respondents who delayed, 105 individuals (13.1%) had Error bars indicate 95% CIs.  Abbreviation: IVF, in vitro fertilization.

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a Numbers may not add to 100% due to rounding. b Responses included "Yes, but as part of IVF/fertility treatment"; "Not yet, but currently in process"; "Strongly considering in the next year"; and "Attempted to freeze embryos but none were genetically normal so have none frozen." concerns about lack of support from leadership "very much" or "extremely." There was no association between fertility knowledge and delay or between specialty and delay.

Discussion
In this survey study, women physicians cited significant career-related pressures as influencing the timing of childbearing and reported marked career alterations to accommodate parenthood. To our knowledge, this is one of the largest studies to evaluate fertility and family building among women physicians and the first survey to evaluate the association of family building and parenthood with career. While we did not limit the survey to US physicians, more than 98% of respondents reported residing in the US, suggesting that these results may be most representative of US-based physicians.
Our findings contribute to a growing body of literature characterizing unique family building challenges among women physicians. The prevalence of delayed childbearing among women in medicine was identified in a 2016 survey 10 and supported by a 2021 retrospective cohort study 7 that JAMA Network Open | Equity, Diversity, and Inclusion found the mean age at first birth to be 32 years among physicians vs 27 years among nonphysicians.
More than three-quarters of female physicians in our survey reported delaying childbearing due to medical training or career. This figure is striking in light of the well-documented decline in female fertility with age. 19,20 Although some studies have suggested low fertility knowledge among physicians, 12,13 our findings agreed with prior data suggesting an understanding of the decrease in fertility with age and showed that respondents had a tendency to underestimate vs overestimate fertility. 10 Importantly, knowledge was not associated with likelihood of delayed childbearing or duration of delay. Given these results, the factors cited as most influential regarding timing of childbearing (ie, lack of schedule flexibility and time, stress, and financial strain) may represent barriers to earlier pregnancy despite this knowledge.
Alarmingly, 36.8% of respondents endorsed a personal history of infertility, among whom more than half required IVF to conceive. In contrast, 6% to 19% of women in the US general population have infertility and 12.2% have used fertility services. 21,22 Although our sample may not be representative, the prevalence was similar to prior estimates. 10

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Childbearing, Infertility, and Career Trajectories Among Women in Medicine Encouragingly, a recent Accreditation Council for Graduate Medical Education mandate specifies that sponsoring institutions must have policies including 6 or more paid weeks of parental leave. 34 While this falls short of the 12 weeks recommended by the American Academy of Pediatrics on the basis of parental and infant benefits, 35 it represents an important step. Policies must be accompanied by cultural shifts to counter concerns that taking leave damages professional reputation 36,37 and leads to loss of career opportunities. 38,39 Furthermore, policies must provide leave for birth and nonbirth parents to counter norms of women shouldering a disproportionate burden of childcare and household responsibilities. Additionally, access to the full spectrum of fertility care must be expanded. In addition to offering insurance benefits and clinical flexibility to the nearly 20% of women physicians who use IVF to conceive, awareness of and access to fertility preservation services should be offered to those desiring greater flexibility in family planning. In this survey study, 11.5% of women underwent oocyte or embryo cryopreservation, and less than 10% had insurance coverage of the procedures. Although the AMA has supported resident physician access to oocyte and embryo cryopreservation, 40 buy-in at the institutional level is needed to implement these benefits and expand coverage to medical students and faculty. Until that happens, access to fertility preservation may be unattainable for medical trainees and junior faculty during the years it is most likely to be effective. 41

Limitations
This study has several limitations. The chief limitation was our inability to calculate response rate due to the unknown number of individuals who received the survey hyperlink. While the number of individuals who began but did not finish the survey was known (76 individuals), most respondents provided insufficient information on which to compare nonrespondents with respondents. Survey respondents were younger vs all US women physicians, indicating some response bias. It is possible that women who personally struggled with infertility were more likely to complete the survey, thereby inflating the prevalence within our sample. However, respondents spanned all levels of training and practice patterns across all regions of the US. The most common specialties included those with predominately women populations, such as obstetrics and gynecology and pediatrics, which may explain the relative overrepresentation within our cohort. Additionally, the reliance on self-report introduced the possibility of recall bias. While we cannot eliminate the possibility of bias, the consistency of findings between qualitative 16 and this quantitative data suggests that while point estimates may vary, prevalence was high and warrants attention. To our knowledge, this cohort represents one of the largest on this topic to date, but no sample size calculation was performed.
Notably, the decision to focus on women was made due to previous data suggesting that women physicians were more likely to delay childbearing, 9 experience infertility, 9 and alter their careers for family reasons. 14,15 Trends among cisgender men physicians and transgender physicians warrant further investigation. Furthermore, the relatively small number of gay and lesbian respondents precluded meaningful evaluation of the potentially distinct challenges and concerns within this population, which should be the subject of future research.
Additionally, given that fewer than 2% of respondents resided outside the US, results may be less applicable to physicians from other countries. While the prolonged duration of medical training and experience of age-related fertility decline are universal, national policies and societal norms may vary and represent an important line of inquiry for future study.

Conclusions
Findings from this survey of women physicians suggest that career-related pressures may be associated with the timing of pregnancy and may contribute to significant rates of infertility despite adequate fertility knowledge and that family building and parenthood may be associated with alterations in the career trajectory of women in medicine. These findings highlight a need for ongoing research into the reasons underlying delayed family building and infertility within this population and